malignant middle cerebral artery infarction and role of ......malignant middle cerebral artery...
TRANSCRIPT
Malignant Middle Cerebral Artery Infarction and Role of
Decompressive Hemicraniectomy
Amrendra Miranpuri, MD Surgical Director, Comprehensive Stroke Center
Objectives • Natural history of malignant MCA infarction (MMI) • The trials on role of decompressive hemicraniectomy
(DHC) • Pathophysiology of MMI • Predictors of MMI • Optimal timing for DHC
“Malignant” MCA stroke
• Approximately 10% of strokes: – Massive, hemispheric – Brain edema, herniation, shift – Hemiplegia, eye/head deviation, aphasia/
neglect – Decline in level of consciousness within
day(s) – Up to 80% mortality
European RCTs on DHC
DESTINY 2007 • 32 patients (18-60) • Infarct >2/3 MCA
territory • NIHSS > 18 (ND) 20
(D) • DHC 12-36 hours
DECIMAL 2007 • 38 patients (18-55) • Infarct >1/2 MCA
territory • NIHSS >16 • DHC <36 hours
• 64 patients (18-60) • Infarct >2/3 MCA
territory • NIHSS >16 (ND)
21 (D) • DHC <96 hours
HAMLET 2009
MRS • 0 – No symptoms at all • 1 – No sig disability despite symptoms; able to carry out all usual
duties • 2 – Slight disability; unable to carry out all previous activities, but
able to look after own affairs w/o assistance • 3 – Moderate disability; requiring some help, but can walk without
assistance • 4 – Moderate-severe disability; can’t walk w/o assistance, unable to
attend own bodily needs w/o assistance • 5 – Severe disability; bedridden, incontinent and requiring constant
nursing care and attention • 6 – Dead
Lancet Neurol. 2007 Mar;6(3):215-22.
Hemicraniectomy: - absolute risk reduction in death: 49% - absolute increase in mRS 2, 3, 4: 12%, 10%, 29%
For every 10 hemicraniectomies for MCA stroke: - 5 will escape death, of which, at one year, 1 will have mild disability,
1 will have mod disability, and 3 will have mod-severe disability (can’t walk independently)
UK Physician Survey of DHC
World Neurosurg. 2017 Feb 21.
Survey Results
• 78 responses (51 neurosurgeons, 27 stroke physicians)
• 54% (60-70 years) 24% (70-80 years) • 60% (48-72hrs) 27% (>72hrs) • 36% (GCS 15)
Survey Results
• Stroke physicians statistically more likely to recommend DHC >60 years (p = 0.032), multi-territorial infarcts (p = 0.042) and accept higher postop mRS (p = 0.034) compared to neurosurgeons
• >1/2 neurosurgeons/stroke physicians recommend DHC >60 years and 48-72 hours
MMI Management
NEUROSURGEON -ICP
NEURO ICU MD -Airway
-Hyperosmolar therapy
-Seizure therapy
STROKE MD -Antiplatelet therapy
-Reducing stroke expansion
Pathogenesis of Malignant Ischemic Stroke
Cytotoxic edema -core infarct
Vasogenic edema -”space occupying lesion”
Brain compression and herniation syndromes -eventual death
Edema
• Cytotoxic edema – Intracellular water accumulation due to Na/K
pump collapse – BBB intact – Due to ischemia – Edema seen in cortex and white matter
Edema
• Vasogenic edema – Increased permeability of capillary endothelial
cells (tight junctions) – White matter primarily affected – Proteins migrate from IV space to EC space
Edema • Progression of cerebral edema 2-5 days • 2/3 deteriorate within 48 hours • 1/3 deteriorate after 48 hours
DHC prior to neurological
decline
DHC outside recommended time interval
58 yo man NIHSS 17 chronic right ICA occlusion
48 hour CT scan 6 mm shift
Pupillometer Hypertonic saline HOB up Q1 hour neuro checks Lengthy conversation with patient/family
96 hour CT scan 14mm shift Increased lethargy
DHC
POD 1 CT scan 30 day mRS 4
Discharge to inpatient rehab
Cranioplasty
Predictors of MMI
• High NIHSS • Large MRI DWI positive infarct territory • ASPECTS <4 • Hyperdense MCA sign • Carotid T occlusion
Predictors of MMI
• 119 patients, 57 developed MMI • Multivariate regression analysis identified
4 independent factors associated with MMI
Journal of the Neurological Sciences Volume 338, Issues 1–2, 15 March 2014, Pages 102–106
DASH Score (each 1 point)
• D………DWI (ASPECTS <4) OR, 4.16 • A………ACA territory involvement, OR 6.9 • S………Susceptibility M1 sign T2* GE,
OR 4.55 • H………Hyperglycemia (>145), OR 5.31
DASH
• 0 (9.1% likelihood of developing MMI) • 1 (20.5%) • 2 (63.0%) • 3 (94.7%) • 4 (100%)
70 yo NIHSS 17, glucose 158, MRI 3.3 h, DWI ASPECT 3, including ACA territory, M1 SVS on T2* ge, ICA occlusion
36 hour MRI demonstrating space-occupying cerebral
edema and brain compression
Poor outcome ~ mRS ≥ 4
Retrospective No stroke volumes No NIHSS Only inpatient data
Results • 1301 patients • 24/48/72 hours evaluated continuously, dichotomously • 55.8% (726) surgery <48 hours • Timing of surgery not associated with in-hospital
mortality • Evaluated continuously later surgery increased OR
discharge to institutional care and poor outcome • Evaluated dichotomously no difference in poor outcome
<48 hours, increased >72 hours • Subgroup analysis no association of timing with
outcomes as long as no herniation sustained
Conclusion
• Establish predictors for MMI at your institution (clinical and radiographic)
• Establish concensus for how to monitor large MCA stroke patients after 48 hours
Thank you!